Dilemmas in Practice: Questioning TPN as the Answer

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Dilemmas in Practice: Questioning TPN as the AnswerAuthor(s): Susan C. HushenSource: The American Journal of Nursing, Vol. 82, No. 5 (May, 1982), pp. 852+854Published by: Lippincott Williams & WilkinsStable URL: http://www.jstor.org/stable/3463053 .

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Questioning TPN as the Answer

By Susan C. Hushen

In the past, fears of accelerating tumor growth and inducing sepsis limited the use of total parenteral nutrition (TPN) in the management of malnutrition in cancer patients. However, studies in the late 1970s revealed that, while there was some increase in tumor size with TPN, there was no marked increase in tumor growth or in sepsis (1-4).

In fact, oncology patients who are supported nutritionally with TPN have shown an increase in tolerance of chemotherapy, a de- crease in the toxic side effects, and an ability to tolerate higher doses of the chemotherapeutic agent(5,6). They have also shown an increase in body weight, resulting in an im- proved physical appearance and a renewed sense of well-being both for the patient and the family.

But TPN has become more than a treatment for malnutrition in cancer patients; it has become a life- support system as well. Therefore, it is important to define ultimate therapeutic goals before it is started. Is TPN to prepare the patient for surgery? Is it for support during chemotherapy or radiation treatments? Is it to restore physical well-being for additional time at home? If it is the latter, when do you halt the restora- tion process? When do you terminate nutritional support?

The following case histories of cancer patients illustrate many of the difficult decisions and issues that initiating TPN can raise.

Case history #1. Charles, a 52-year-old man who had under- gone resection of a gastric carcinoma three months before, was admit- ted complaining of nausea, vomit-

ing, and epigastric discomfort. Gastroscopy revealed recurrent tumor. On admission, Charles was 7 kg (15 lb) below his ideal body weight of 78 kg (172 lb).

TPN was initiated to prepare Charles for surgery. An exploratory laparotomy was performed 10 days later. In addition to recurrent carcinoma, surgical findings revealed seeding of the peritoneum, bowel, and liver, as well as extensive adhe- sions. No definitive operative proce- dure was performed. TPN was continued, and 11 days later radiation therapy was begun.

During the radiation therapy, Charles developed continuous, se- vere hiccups. Multiple phrenic nerve blocks were performed with minimal effect. A nasogastric tube to continuous suction was the only successful treatment.

Radiation therapy was stopped after 28 days; the gastric tumor had not responded.

Despite the fact that the patient required morphine sulfate every hour for constant pain and no further treatment could be offered, TPN was continued for five more days. He had received TPN for 54 days and had gained seven kg.

Four days after TPN was discontinued, the patient died.

Case history 42. Darlene, a 52-year-old woman who had meta- static carcinoma of her ovaries and both breasts, had been hospitalized and treated with multiple chemotherapeutic agents. Two days after discharge, she was readmitted with bleeding gums and a large hemato- ma over the left buttock at the site of a previous injection.

CBC on admission showed a 7.1 hemoglobin, 20.9 hematocrit, 400 white cell count, and a 10,000 platelet count. Pancytopenia sec- ondary to the chemotherapy was diagnosed.

Shortly after admission she developed nausea and vomiting and was unable to eat. The progress notes described her condition and prognosis as grave. Nevertheless, TPN was initiated.

Two days after nutritional support therapy was started, Darlene stated that she felt better, despite continuing nausea and vomiting. A tentative diagnosis of partial intesti- nal obstruction was made; but, because of her "terminal" status, surgery was not done.

Over the next two weeks, she showed signs of physical and emotional deterioration. She was angry and depressed. During this time, Darlene had received 60 units of platelets, but her platelet count nev- er rose to a satisfactory level. She grew progressively weaker and developed bronchopneumonia.

TPN was continued until the day the patient died.

What Are the Questions?

With the technological ability to prolong life with artificial organ support systems, including TPN, the question is no longer "How can we sustain life?" but "Should we?"

Charles, the patient with gastric carcinoma, brings many of the typical ethical dilemmas associated with TPN into sharp focus. When he entered the hospital, he clearly needed nutritional support to gain weight prior to surgery.

In addition, the nutritional re- pletion was associated with an im- proved sense of emotional well- being for both the patient and his wife. After his gastrectomy, his wife had tried unsuccessfully to help him regain weight. She had exhausted all dietary possibilities and was her- self becoming exhausted, frustrated, and angry. With TPN, her husband was beginning to gain weight and

SUSAN C HUSHEN, RN, BA, is a nurse clinician in nutritional support at Newark Beth Israel Medical Center in N. J.

852 American Journal of Nursing/May 1982



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feel stronger; Charles's wife felt that the gaunt patient in the hospital bed was slowly being transformed back into "the man I married."

Following the "open-close" laparotomy, the rationale for continuing nutritional support was to maintain Charles through a course of radiation therapy. But as the radiotherapy progressed, it became obvious he was not responding to treatment, and both his physical and emotional state began to deteri- orate rapidly. He experienced constant pain, though he often refused the pain medication because it made him too sleepy to visit with his wife. Nutritional support continued. To stop would have been admitting imminent death to the patient as well as to his wife. No doctor or nurse directly involved could or would take such responsibility. TPN was continued until the patient became comatose.

Would Charles have died soon- er, and have been spared days of pain, without the nutritional support? In administering TPN, were we just giving food? Or were we doing more?

If nutritional support is more, if it is an extraordinary means of sustaining life, when and how can the decision be reached to remove the lifeline?

Deciding to stop TPN is not analogous to "pulling the plug" on the respirator connected to a comatose body with fixed and dilated pupils. Usually, it is removing a catheter from a talking, feeling, thinking person.

Why do physicians initiate TPN? Why are some terminally-ill patients nutritionally supported, while others are not?

Again, in the case of Charles, TPN was initiated for apparently good reasons. But when it became apparent that Charles was not responding to radiation treatments, the-primary reason it was continued was because the family would not permit it to be discontinued.

Families who request that everything possible be done to help a patient are certainly within their rights and are acting out of love. In

dealing with end-stage cancer, however, the time, energy, and financial resources used might sometimes be better expended on supportive counseling for the family.

Another reason for not stopping nutritional support in end- stage cancer is the fear that it might have medicolegal ramifications. Must the courts be involved in stopping TPN in the terminally ill? The courts have a history of trying not to become involved in such problems. In deciding whether or not to stop life support systems, they have fol- lowed physicians' definitions of brain death as a criterion. But terminal cancer patients don't fall into this category. One would hope that the issue of nutritional support will not become a legal decision.

In addition, there is the issue of morality. What are the moral and religious implications of stopping nutritional support in the terminally ill patient and how does organized religion view these issues? The Ro- man Catholic Church is a strong and vocal opponent to euthanasia. But on the question of stopping nutritional support in the end-stage cancer patient, it appears that one is on safe moral ground(7). A docu- ment titled, "The Duty to Preserve Life," makes this distinction: ".... certain means (oxygen, IV feedings, blood transfusions) would be considered ordinary means to bring a patient through a crisis. But long-term use could make them ex-

traordinary".... Active euthanasia (mercy killing) is wrong. Passive euthanasia (letting one die) is permis- sible if it involves omitting extraordinary means; it is wrong if it involves omitting ordinary (and use- ful) means"(8).

In terms of treatment guide- lines, the' medical literature is now replete with statements regarding the propriety of instituting parenteral nutritional support:

"The decisions to initiate and to maintain adequate total parenteral nutrition should be based upon the achievement of a specific, defin- able and realistic goal in each patient .... the ultimate aim of the technique is to prolong meaningful

life, and not merely to prolong the process of an inevitable death"(9).

"Parenteral nutrition has no justifiable role in the treatment of the terminal cancer patient"(10).

"Patients generally should not be started on parenteral feeding if their disease process precludes the reasonable possibility of recov-

ery..."(11). "... TPN should be reserved only for those nutritionally depleted patients who could achieve signifi- cant palliation from radiotherapy and/or chemotherapy... "(12).

Many of these patients have been under care for a long time and have experienced frequent hospital- izations. During this time, a strong bond often develops between the patient and family and the physicians and nurses. Gazing into the sunken, hollow eyes of a cachectic patient dying of cancer and into the hopeful eyes of his loved ones makes it very obvious that it appears to be easier to write these definitive statements and to agree with them in principle than it is to apply them at the bedside.

References

1. Copeland, E. M., and others. Nutrition as an adjunct to cancer treatment in the adult. Can-

cer Res. 37:2451-2456, July 1977. 2. Rapp, M. A., and others. Hyperalimentation,

special nutrition therapy for the cancer patient. RN 39:55-61, Aug. 1976.

3. Ota, D. M., and others. Total parenteral nutrition. Surgery 83:503-520, May 1978.

4. Deitel, M., and others. Specialized nutritional support in the cancer patient: Is it worthwhile? Cancer 41:2359-2363, June 1978.

5. Copeland, E. M., 3d., and others. Intravenous hyperalimentation as an adjunct to cancer chemotherapy. Am.J.Surg. 129:167-173, Feb. 1975.

6. Dudrick, S. J., and Ruberg, R. L. Principles and practice of parenteral nutrition. Gastroenter- ology1 61:901-910, Dec. 1971.

7. Kukura, Joseph. (Assistant professor of Chris- tian Ethics, Immaculate Conception Seminary, Darlington, N. J.) Personal communication.

8. Connery, J. The Duty to Preserve Life, Wash- ington, D. C.: Committee for Pro-life Activities, National Conference of Catholic Bishops, 1977.

9. Cowan, G. S., and Scheetz, W. Intravenous Hyperalimentation. Philadelphia, Lea & Fe- biger, 1972, p. 112.

10. Fischer, J. E. Total Parenteral Nutrtion. Bos- ton, Little, Brown & Co., 1976, p. 295.

11. Steiger, E., and Fazio, V. W. Total Parenteral Nutrition: A Clinical Manual of Principles and Techniques. Irvine, Calif., McGaw Labo- ratories, 1976, p. 3.

12. Deitel and others, op.cit., p. 2363.

854 American Journal of Nursing/May 1982



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Dilemmas in Practice: Questioning TPN as the Answer